Experiences with pain management for survivors of complex cancers: Focus on opioids and cannabis.
Authors: Talya Salz, Susan Chimonas, Sankeerth Jinna, Jessica Brens, Anuja Kriplani, Andrew L. Salner, Guilherme Rabinowits, Maria Currier, Robert Michael Daly, Deborah Korenstein
Journal: Journal of Clinical Oncology (2023)

12118 Background: Survivors of complex cancers often experience pain. Clinical practice guidelines for pain management in cancer survivors cautiously recommend opioids and cannabis for subgroups with certain pain phenotypes, despite limited evidence regarding benefits and harms in survivor populations. We aimed to better understand pain management for these survivors, focusing on attitudes toward, and experiences with, opioids and cannabis. Methods: We conducted 7 90-minute focus groups with 26 disease-free survivors of head and neck and lung cancer who still experience cancer-related pain. Multiple coders conducted thematic analyses to identify themes regarding 1) experiences with post-treatment pain and pain management and 2) utilization, benefits, and harms of post-treatment cannabis and opioids. Results: Survivors (7-35 months from treatment completion) experienced post-treatment physical and psychological pain that affected multiple aspects of their daily life. Since treatment completion, 69% used opioids previously and 8% currently using. Fifty-four percent had used any cannabis product since treatment completion, and 35% currently use cannabis. While some survivors experienced no pain management challenges, others enumerated various difficulties, including fears of addiction to opioids or cannabis, perceived stigma around both products, and access challenges around provider attitudes, cost and insurance coverage, and legality. Survivors reported that providers did not know how to advise about cannabis; for example: “When I talked [to providers] about marijuana they didn’t want to talk about it. They couldn’t recommend it because there’s no clinical data.” Opioids were often perceived as critical to pain management but came with unpleasant side effects. Cannabis was effective at reducing both pain and anxiety for many, but not all, survivors. For some, cannabis reduced anxiety, which in turn reduced pain: “It just keeps my mind occupied enough where I’m not thinking of pain.” Reducing anxiety also helped some survivors eat: “I have a lot of anxiety around eating because I have a fear of choking, so sometimes it helps that.” Survivors described a balance of benefits and harms of opioids and cannabis; for example: “Where [the doctor has] me now...if I go down any lower, it's not going to work. If I go up any higher, I'm going to be not able to function.” Conclusions: Post-treatment survivors of complex cancers continue to experience cancer-related pain, both psychological and physical, for which both opioids and cannabis present a complex set of harms and benefits that vary across survivors. Providers who care for cancer survivors should be aware of the interplay between psychological and physical pain, patient concerns and stigma around opioids and cannabis, and nuances of the harms, benefits, and access issues regarding these treatments.